Pointing the Finger Versus Blaming the System

Some healthcare facilities have adopted a "blame-free" culture in which all errors are attributed to system failures. On the opposite end of the spectrum are overly punitive facilities in which an individual or individuals are blamed for errors that occur. Some authors have called these individuals the "second victims" of the error because of the emotional trauma that they experience. The National Quality Forum (NQF) has developed a Care of the Caregiver standard that recommends that hospitals treat traumatized healthcare providers involved in errors as patients requiring care, and then involve them in the root cause analysis to determine how things went wrong.

In addition to malpractice allegations, serious and fatal healthcare errors sometimes trigger criminal charges against the healthcare providers who made unintentional errors. This has added to the complexity of the issue of who or what is to blame when an error occurs? Safety experts are concerned that adding criminal charges sets a precedent that will further drive errors underground and make healthcare providers less likely to report them.

Research suggests that healthcare errors are not entirely "blame-free" because healthcare providers sometimes bypass or ignore safety standards and procedures. However, there are usually a number of system failures that also cause, or contribute to, the errors made. Healthcare providers need to be treated fairly when an error occurs, but they also need to be accountable for their actions. In the root cause analyses of some errors, healthcare providers were found to take risks and short-cuts, manually override safety systems, and bypass or ignore safety measures. I believe there is a middle ground, but that "middle ground" will vary from situation to situation. Each error is unique and needs to be reviewed in the context in which it occurred. There is no universal "one size fits all" approach; however, consideration does need to be given to personal accountability as well as the system in which the error occurred.